The Abortion Dictionary is a fortnightly blog series and is an attempt to dispel myths and provide safe and reliable information about safe abortion and attendant issues. We start with the basics and cover a range of topics from A-Z, quite literally! Happy reading!

Abortion

The word conjures up a myriad range of images, emotions, taboos, and practices.

But what is it? The dictionary, quite clinically, refers to abortion as the deliberate termination of a human pregnancy, most often performed during the first 28 weeks. Since time immemorial, women across the world have used a range of traditional home-based practices to terminate unwanted pregnancies for a variety of reasons using whatever techniques, knowledge, and resources they had at hand. Today, the development of modern medicine guarantees women a method of safe abortion that does not jeopardise their health, or put their lives at risk.

As of 2014, it is estimated that approximately 36 abortions occur each year per 1,000 women aged 15–44 in developing regions, and 27 in developed regions. And yet, the World Health Organisation reports that 45% of all abortions globally are unsafe, which adds up to a staggering number of 25 million unsafe abortions, causing 6.9 million women to be treated for complications arising from unsafe abortions annually. [1]

Much has been said about how ensuring women’s health and rights leads to all-round social gains – economic and otherwise. Indeed, the recognition of this fact is what guided the inclusion of sexual and reproductive health and rights as fundamental to people’s health and survival in the Sustainable Development Goals.

What then prevents women from accessing safe abortion services that are critical to their sexual and reproductive health and wellbeing?

There are a number of explanations that explain women’s inability to access safe abortion services.

One of the main challenges to accessing abortion services is the lack of a legal framework guaranteeing access to abortion services. It is well established that legal abortions are a relatively recent phenomenon with the amendments to criminal codes allowing for abortions only taking place in the mid-to-late 20th century.[2] Indeed, countries like Ireland have only recently won the right to access safe abortion legally, and others like Poland and Argentina continue to fight for the right.

It is necessary to make available both legal and safe abortion services for women; a lack of legal option does not stop women from having abortions, it only necessitates women using unsafe and dubious means of terminating their pregnancies, putting their lives at risk.

The second major challenge to accessing safe abortion services is abortion-related stigma, which cuts across all contexts, continues to negatively affect women’s health and well-being. Accessing safe abortions is strongly influenced by the fear of being recognized by family and friends, the feeling of having done something “wrong”, and of misconceptions about what having an abortion means for future fertility and reproductive health. For as long as such stigma persists, so will unsafe procedures as women avoid trained providers in formal medical settings for the fear of being shamed or judged. [3] Even in countries where abortion is broadly legal, women’s feelings of having a stigmatized procedure can result in their fear of being judged harshly by health professionals, and of being treated as an outcast by their family and community. [4]

A number of other challenges such as cost, availability of trained medical professionals, robust health infrastructure, medical patriarchy all interact to make access to safe abortion close to impossible. Governments, medical associations and civil society organizations must spread the word about any changes in abortion law—most urgently to women, but also medical personnel (including administrative staff) and law-enforcement professionals. Unclear laws and service provision guidelines need to be clarified, especially where abortion continues to be strongly stigmatized. In addition, national health systems must create the required service-provision infrastructure and train personnel, as well as develop, issue, communicate and apply new guidelines.

Only through this can we ensure that women have the ability to exercise control over their own bodies even when institutional provisions exist to guarantee services to women, and no more women’s lives are lost to entirely preventable circumstances.

This blog has only scratched the surface of the debate around access to safe abortion. If you’re keen on learning more, stay tuned to our #AbortionDictionary series as we write about challenges, successes, and issues that relate to the right to safe to abortion.

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The last decade has seen a drastic increase in the number of people who are displaced or living in conflict zones, and in need of humanitarian assistance. As is the case when it comes to living with vulnerabilities, the lives of women and children, especially young girls, face the brunt of marginalization. In 2016, it was estimated that of the approximately 100 million people who were targeted with humanitarian aid, an estimated 26 million were women and girls of reproductive age.[1] It is perhaps then, unnecessary to underline that the sexual and reproductive health and rights of people living in emergency situations, particularly women and girls, requires urgent attention.

It is a well-known fact that crises exacerbate existing violence against women and girls, and present additional forms of violence against girls and women. The insecurities inherent to conflict situations, and subsequent life as a refugee gives rise to many forms of gender-based violence (GBV), including sexual violence, threats of trafficking, and forced marriage. Further, girls and women are often more greatly affected by both sudden and slow-onset emergencies, and often face diverse sexual and reproductive health challenges. The violence faced by women is further compounded by the fact that these women have limited access to healthcare, and when they do, health care systems refuse to acknowledge the consequences of such sexual violence[2]. As a consequence, in addition to being serious human rights violations, these abuses contribute to unintended pregnancies, and in turn, can lead to high rates of unsafe abortion and maternal mortality. According to UNFPA estimates, three-fifths of all maternal deaths globally, take place in humanitarian and fragile contexts. Of this, between 25–50% of maternal deaths in refugee settings are due to complications of unsafe abortion.[3]

There is an immense need for health systems to enable women to exercise autonomy by providing effective contraception, as well as the ability to terminate unwanted pregnancies legally and safely.

It is this context that our interview with Rola Yasmine, Founder, The A-Project, Lebanon, becomes even more significant. Last year, she had spoken with us about her work with Syrian women who are refugees in Lebanon; we’ve reproduced part of that conversation here:

Can you talk about the inter-linkages between sexual violence and abortion rights in your work with displaced/refugee women?

I think actually focusing only on sexual violence may not necessarily be the only angle to talk about displaced citizens and violence against women. I think to some extent, people want to see more of sexual violence in refugee settings because there’s a demand to have images that pity and victimize women. But there is so much violence against women who are displaced that is not necessarily sexual by nature. I think that institutionalized racism and xenophobia limits refugees’ access to all sorts of basic services, especially for reproductive health and safe abortions and that is also violence against women.

Women tell me that they go to pharmacies to get contraception or to get misoprostol and pharmacists harass them not because they want to do abortions but because they are Syrian, blatantly saying “is this really the time for you people to be procreating?” These kinds of statements are not only said by pharmacists but also from physicians, midwives and nurses, and not only Lebanese but also Syrian doctors and midwives of middle-class upbringing.

The educated middle class do not see that even in the middle and upper classes, people have unprotected sex all the time and women become pregnant and have unwanted pregnancies, they just have money enough to cover it up. The lives of people in poverty are just so exposed and so transparent so it’s so easy to point at them and say “wow you guys are really behind.”

Can you talk about women’s experiences accessing abortion?

One woman called us from a refugee camp in the North of Lebanon; she was a widow and had 2 children, one whom had an untreated serious health condition of Hydrocephalus. She re-married thinking that it may help her take care of her children, but the man she married was a divorcee who had a child that he wanted someone to take care of which is why he was looking to remarry. He was physically violent and severely abusive and would keep threatening her with divorce although he gave her nothing in monetary value to her or her kids. She was looking for an abortion, but it was a little difficult and when she finally asked for it she faced resistance. She started taking all sorts of over the counter medication.

While less frequent, there have been callers who have faced sexual violence and rape and calling for post-abortion care. A widowed Syrian woman was raped in a refugee camp and she couldn’t tell anyone about the rape because it was a powerful and violent Lebanese man in the camps. She was worried that if she said she was raped, people may think she was doing sex work.

What is the role played by the International NGOs (INGOs) involved?

Service providers in INGOs asking women if they are married may be a deterrent to care for those who are separated, widowed, unmarried, divorced, and/ or doing sex work. Many women have said that they keep getting told to come to counselling and mental health sessions to talk and re-talk rape that she’s experiences and process it, while they are usually looking for safety from a repeat offender or an abortion if the rape resulted in a pregnancy.

It isn’t surprising that talking to a counsellor isn’t on the top-ten list of needs to many refugees. What is upsetting is that you hear service providers wrongfully presume that refugees reject mental health counselling because of the stigma around the field and it not be seen as a real science – when it’s just seen as a bit of a luxury at this point or foreign practice at any point in their lives.

What do you see as the role of The A Project in this context?

The A project works on giving information about reproductive and sexual health as well as referrals subsidized or free services. We work on politicizing the conversation around sexuality and gender, whether with local activists or healthcare providers.

Part of the A Project really is the launch of a Hotline to talk about all things to do with sexuality and gender so you don’t get a washed down answer on how effective a condom is and its 3% failure rate. But you talk about the politics of how it’s really difficult to negotiate it sometimes, the barriers that aren’t as easy to quantify. So it is to have the conversation within feminist politics and expose medical patriarchy. We also do political sensitization trainings for health care providers.”

We work on producing feminist research and knowledge that responds to the patriarchal hegemony that demonizes and problematizes the agency and autonomy of young women, queer women, refugee and migrant women, sex workers, and gender non-conforming folks.

So you may have heard the news that broke over the weekend about Morgan Freeman aka Hollywood face of God who has been accused by 8 women of sexual assault.

It is a terrible blow to imagine that the Voice we all love and the smiling wise character of God he always played has turned to dust in our mouths. His net assets are worth 200 million dollars so of course, he has good lawyers and he has, of course, issued a denial.

As did Bill Cosby initially. And Woody Allen. And Harvey Weinstein. And…….

But you know what? Whatever the eventual outcome, this is a good thing! It seems unfair in case he does turn out to be innocent, but this is lifting the final curtain and peeking beyond the shadows on the walls of our cave.

Plato’s cave is one of the most important and powerful allegories forming the basis of Western philosophy.

Briefly– it talks of a cave where some people are held and they only see shadows on the walls of the cave as things move around outside. One of them finally goes out and sees the actual reality which is casting the shadows. He comes back to tell them and they threaten to kill him for breaking their illusions.

That, in a nutshell, is most people……

We may speak of Feminism and Equality endlessly but Patriarchy and Power will never be amenable to mere ‘modification’. The entire edifice needs to be shattered, the uprooting and rebuilding may take raging ages and cause a lot of collateral damage, but this is a war that has to be won.

This is what Jessa Crispin is saying in her book Why I am not a Feminist. She says we cannot work on the inside to change this structure that imprisons us all. Do not be under any delusion that patriarchy is good for all men either! It is good only for those who are heteronormative or rich or educated or high caste but yes, within any intersection the men will ALWAYS have more privilege than women, and hence the continued need for feminism.

But perhaps the time has come to stop negotiations and begins the demolition.

How long will we just accumulate lists?

Abuse by Church ‘fathers’: Wikipedia actually has an alphabetized list by country. Seriously.

There is also a long list of our own ‘Gurus’ and Swamis in India accused and found guilty of a range of sexual assault, rape and other such cases.

Bill Clinton who inserted a cigar into Monica Lewinsky’s vagina and then said under oath ‘I did NOT have sexual relations with her’.

Rape as a weapon of war: “In the sick logic of war, rape is a highly effective weapon. Its crippling effects can last for years. By creating shame and humiliation it destroys ties within families and communities. It silences and paralyzes. We know it’s a crime. It’s been defined as one in international law. But it’s still happening. And it will continue to happen until we can make the perpetrators truly accountable.”

We see it everywhere, in all ages and spaces. Women have endured witch burning, dowry deaths, female infanticide, violence, rape, abuse.

From the Boko Haram kidnappings: After the 270 they kidnapped so many years ago, they recently kidnapped 110 more. It did not even make front page news.

To our beloved Indian government which refused to criminalize marital rape. “India’s government has rejected calls to outlaw marital rape after saying it could destabilize the institution of marriage and put husbands at risk of harassment.”

Statistics say one woman is raped every hour somewhere in India. Most rapes are by someone known to the survivor. You do the math.

Even the relationship between Brahma and Saraswati is a bit dodgy, to say the least. Did she not exist before him? Or was she his daughter or his consort? Or both?

Kali and Durga as goddesses have always had to rise only to fight evil men.

It is time now to use our energies to not just have to defend and attack but to grow a positive human civilization, not a ‘man’ made one.

As Alexander Solzhenitsyn says “The battle line between good and evil runs through the heart of every man.”

Maybe someone like the Girl with the Dragon Tattoo can photoshop the face of Morgan Freeman away from everything and replace it with Toni Morrison or Arundhati Roy or Beyonce or Ruth Baden Ginsberg.

Or better still, replace it with a mirror so we can recognize the power within all of us to harness the good and overcome the evil.

As Nietzche said ‘God is Dead’. He used the phrase in a figurative sense, to express the idea that the Enlightenment had “killed” the possibility in a belief in any god having ever existed.

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This blog is part of a series that catalogues the learnings and the reflections from the recently conducted 10th Anniversary Conference titled the ‘Power of Partnerships’.

Riti Sanghvi, Youth Champion, India

It is a universally acknowledged truth that medical students have to go through an incredible no. of pages in their undergraduate years. Despite this, we often fail to learn about socio-political-cultural practices and patriarchal systems and their effects on sexual and reproductive health.

In a country like India, where topics of contraception, sexuality and even menstruation have been heavily stigmatized, it seems like forever before we even discuss abortion, making abortion look illegal. And even though our country has quite a liberal abortion law, it lacks clarity and is not a rights-based document. It requires doctors to exercise their judgment and this is where doctors can often impose unnecessary restrictions. This limits access to abortion despite a law which was seen as very progressive when it was passed in 1971.

Thus, it is time that we address the potential of doctors as agents of change and start conversations around safe abortion as a human right, and not just a medical procedure and a public health issue.

This is where ISAY comes into the picture. ISAY was founded by a group of medical students from Mumbai, who are passionate about leading the work of safe abortion advocacy amongst fellow students after attending the YAI organized by ASAP. We at ISAY propose to sensitize key stakeholders i.e. mainly medical students and other healthcare workers involved.

Becoming a doctor is a long and often difficult process where knowledge and attitudes are shaped not just by textbooks, but by teachers and seniors. We spend up to 10 years in college without ever hearing the words misogyny or patriarchy, though its reflections are obvious in almost every textbook and teaching. These are the aspects of abortion and other reproductive health problems which our textbooks and teachers fail to address. We would like to create a future where doctors are sensitive, aware, and empowered to bring about change in health and well-being of a person as a whole. This is only possible if we start right from when they are medical students.

Textbooks and healthcare training should sensitize medical students on patriarchy, and its impact on decision making power for women regarding sex and contraception, its relation to interpersonal violence , unwanted pregnancies and the constraints that women, especially poor, young, unmarried from rural areas face in seeking access to abortion, which very commonly lead to unsafe abortion practices, hence leading to complications.

I have also been working on the analysis of the current level of gender sensitivity in the textbooks being used for undergraduate medical training and the potential impact that it has on developing attitudes.

Here is an example of the language in the textbooks which reflects not only facts but the attitude or even prejudices of the authors, thus creating a bias in the minds of students who have never been exposed to the other perspectives related to the issue in discussion.We have been trying to overcome these issues by carrying out sensitization workshops and YAIs for medical students across 5 medical colleges from Mumbai and beyond, building awareness among them on topics of gender, power, patriarchy, sexuality and building a rights-based perspective for abortion issues.

Our very first Youth Champion, Mubasshir Babar, organized the first sensitization workshop in Mumbai along with ASAP and the Medical Students’ Association of India, in May 2016 and till date we have conducted 4 such workshops and 4 YAIs reaching out to a total of close to 200 students. We have all been conducting sessions as peer trainers with the support of the trainers from ASAP and most of us have also had an opportunity to attend the Youth Advocacy Refresher Institute where we were able to engage in on depth with issues such as ethics, sexuality, neoliberals economic policies, law and using theatre as a tool for resistance.

We also hope to have more participation from students of various colleges across Maharashtra, but most medical students find it difficult to make time for such workshops, and therefore it is crucial that eventually, this becomes a part of our medical curriculum. And even though we have only worked with students as for now, we hope to reach out to our faculty members and encourage them to have a healthy discussion with the medical and nursing students and staffs, explaining to them the urgency of this.

We are very much determined to work on safe abortion issues as well as continue involving more healthcare workers through these workshops and collaborate with other organizations working for a similar cause.

This is only the beginning, a bigger change is due. Not only medical students, but many young people outside of the medical field are also strongly committed to gender and rights issues and we would work to include them and create a diverse network/ group of young individuals working to improve access to safe abortion for women and girls in India.

Safe Abortion is every woman’s right and we should provide it regardless of our religious belief and political stand. And even though we are all not going to Obstetricians, gynecologists or direct abortion providers, the way we talk about abortion in our community is going to influence decision and policy-making, and even direct provision of it. It’s time we understand that abortion is a human right and we as doctors don’t get to make decisions about anyone’s body.

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This blog is part of a series that catalogues the learnings and the reflections from the recently conducted 10th Anniversary Conference titled the ‘Power of Partnerships’.

– Smriti Thapa, Youth Champion, Nepal

I hear and I forget, I see and I remember, I do and I understand: Chinese proverb

The first time I saw Dr. Ea Mulligan doing a Papaya workshop was in in ASAP’s Gender and Medical curriculum meeting in Vietnam. I was so thrilled and fascinated by the idea of trying MVA in a fruit, which further inspired me to bring this amazing learning experience back home among my students. As a result of which, I conducted similar workshops among my students. Before each workshop, I went through a lot of presentation video clips on it (as well as the TEACH abortion training workbook developed by Dr. Sarah Mc Neil (at TEACH in California)

To be able to join Dr. Ea for a similar demonstration during the two days of ASAP’s Anniversary Conference was another learning curve for me. This time, we tried the procedure with a dragon fruit and it was much better in terms of the process of evacuation since it was more reflective of the actual evacuation of the contents of the uterus during the termination of pregnancy in comparison to a papaya.

The demonstration was set up for both days of the conference and I had this opportunity to help Dr. Ea as one of the facilitators of the demonstration. Along with the Manual Vacuum Aspiration, she also demonstrated the use of IUCD in a dragon fruit and we were able to demonstrate that to other participants. Not only did the participants see our demonstration, but they also had a chance to do some hands-on skills practice.

Some of the participants with backgrounds in medical science really found this procedure simple and non-threatening, and felt that this will help them tackle the anti-choice rhetoric which often shows old and outdated sharp instruments to describe surgical abortion, when in reality MVA has really shifted the paradigm of abortion services. On the other hand, a few others, especially with non-medical backgrounds, weren’t quite sure of how much this learning was useful to them. Nevertheless, they enjoyed the hands-on practice and were excited to share their experience with other people. The majority of them were really curious and excited to see the contents coming out of dragon fruit after being sucked by manual vacuum aspirator and were struck by how simple the overall procedure was.

The entire setup wouldn’t have been possible without the amazing Dr. Ea Mulligan and Dr. Dalvie whose relentless support and guidance for the demonstrations really helped the stalls team of me, Riti and Thuy to develop the necessary background for the successful outcome of the demonstration.
Personally, it was a great learning curve for me and I really hope it has inspired abortion advocates, both with medical and non-medical background to really think of abortion as a simple and quick procedure, and further debunk the myths associated with it.